2015 EMPIRE PLAN BENEFIT SUMMARY For Active Employees and Retirees PRE-ADMISSION CERTIFICATION
Prior authorization of inpatient hospitalization charges required. $200 penalty for failure to precertify. No coverage for days not considered to be medically necessary.
You MUST call Empire BlueCross BlueShield at 1-877-769-7447, option 2:
Before any elective (scheduled) hospital admission that will include an overnight stay in the hospital
Before the birth of a child (call as soon as the doctor confirms the pregnancy) – an additional call is required if admitted to the hospital during the pregnancy for complications or for anything other than the delivery of the baby.
Within 48 hours after an emergency or urgent situation – this includes admission if scheduled for outpatient surgery and the patient remained in the hospital overnight due to complications
Before admission to a skilled nursing facility, including transfer to a skilled nursing facility from a hospital
You MUST call United HealthCare at 1-877-769-7447, option 1 for:
Prospective Procedure Review (Prior authorization for any non-emergency MRI, MRA, CT, PET and nuclear medicine diagnostic procedures)
Outpatient Case Management (A voluntary program to help identify and coordinate covered services that a patient needs)
Voluntary Specialist Consultant Evaluation (A voluntary second opinion program)
IMPORTANT:
CVS Caremark - Prescription Drug Coverage 30-day supply retail and mail order:
$ 5 generic
$25 preferred brand name $45 non-preferred brand name
90-day supply retail: 90-day supply mail order:
$10 generic $5 generic
$50 preferred brand name $50 preferred brand name
$90 non-preferred brand name $90 non-preferred brand name
Effective 1/1/2013, The Empire Plan Prescription Drug Program for Medicare-primary enrollees and dependents changed to The Empire Plan Medicare RX, which includes Medicare Part D benefits with expanded coverage designed specifically for NYSHIP. For more information, see page 5 of the Choices 2014 booklet:
http://www.cs.ny.gov/ebd/ebdonlinecenter/choices14/actives/NYPE_ACT_SET_Choices_2014.pdf Effective 1/1/2013, members are required to obtain two 30 day fills of certain maintenance medications through a retail pharmacy prior to obtaining a 90 day fill through a retail pharmacy. Note: This does not apply to specialty medications (see below).
The Empire Plan has a flexible formulary that excludes prescription drugs from coverage. An excluded drug is not subject to any type of appeal or coverage review, including a medical necessity appeal.
Prior authorization is required for certain drugs
The Specialty Pharmacy Program offers enhanced services to individuals using specialty drugs, such as those used to treat complex conditions and those used to treat complex conditions and those that require special handling, special administration or intensive patient monitoring. Most specialty drugs are only covered when dispensed by The Empire Plan’s designated specialty pharmacy, Accredo. You are covered for an initial 30 day fill of your specialty medication at a retail pharmacy but all subsequent fills must be obtained through Accredo.
A pharmacist is available 24 hours a day to answer questions about your prescriptions Call CVS Caremark at 1-877-769-7447, option 4, to find participating pharmacies, find out if your medication is a specialty drug on the Preferred Drug List (PDL) or obtain prior authorizations for certain drugs.
UNITED HEALTHCARE (Participating Provider)
Office Visit $20 copay
Office Surgery $20 copay
Outpatient Surgery (non-office setting) $60 copay
Services NOT subject to copay: Chemotherapy, Dialysis and Radiation Therapy
Single or Series of Lab Tests $20 copay
Single or Series of X-rays $20 copay
Routine Physical No cost; some tests have age limitations
Well Child Visit No Cost
Immunizations (includes influenza,
pneumococcal, pneumonia, measles, mumps, rubella, varicella, tetanus, meningitis)
No Cost for most adult immunizations (vaccines purchased at pharmacies are not covered)
Herpes Zoster (Shingles) Vaccine $20 office visit copay applies for individuals age
If there is both an Office Visit charge and an Office Surgery charge by a participating provider in a single visit, only one $20 copay will be charged.
Only one $20 copay should be charged for lab and x-ray if both services occur during the same visit and are billed by the same provider.
All participating provider office copays apply to the annual major medical copay maximum, but are not covered major medical expenses.
If an office visit is combined with other services (surgery, x-ray, lab) a $40 maximum copayment can be charged per visit, per provider.
Participating providers do not automatically send you to another participating provider or laboratory. In addition, they might not send your tests to a participating laboratory. Please note that all hospital laboratories do not participate with United HealthCare, the portion of the Empire Plan that handles referred laboratory specimens.
It is your responsibility to tell your provider that you want to use Empire Plan participating providers whenever possible. Always check with the provider directly before you receive services to be sure that they are participating. If they do not participate, you will be responsible for the deductible, then 80% of R&C. You can also call United HealthCare at 1-877-769-7447, option 1 or visit the website at
www.cs.ny.gov Click on Employee Benefits and then on Empire Plan Providers.
BASIC MEDICAL (Non Participating Providers)
2014 Annual Deductible $1,000 for enrollee; $1,000 for spouse or domestic
partner; $1,000 for all dependent children
2014 Out-of-Pocket Maximum (includes copays) $3,000 for enrollee; $3,000 for spouse or domestic partner; $3,000 for all dependent children
Pediatric Immunization & Injectible Substance Covered expense (Subject to deductible and coinsurance)
Well Child Visits 80% of R&C after deductible
Routine Physical No coverage under age 50
Employee or spouse/domestic partner over 50: covered at 100%
Not subject to deductible or coinsurance
(immunizations are not covered)
Ambulance Benefit $35 copay
Hearing Aids $1,500 per hearing aid per ear, once every four
years
Children age 12 years and under are eligible to receive a benefit of up to $1,500 per hearing aid per year, once every two years
Prosthetic Wigs $1,500 lifetime maximum per individual
Annual/Lifetime Maximum Unlimited
BLUE CROSS – Member Hospital
Anesthesiology, pathology and radiology paid in full even through non par provider
Outpatient Hospital Services $40 copay
Emergency Room No copay
Chemotherapy, Radiation Therapy, Hemodialysis Performed as outpatient hospital services – No copay
Physical Therapy (when related to prior hospitalization)
$20 copay
BLUE CROSS – Non-member Hospital
Inpatient Services 90% reimbursement of covered charges
Outpatient Services Enrollee pays 10% of covered charges or
$75 copay, whichever is greater
VALUEOPTIONS
ValueOptions administers the Empire Plan’s mental health and substance abuse benefits. Two Benefit Levels apply: network and non-network
Network - benefits are paid in full and you pay $20 copay
Non-network - If you seek care from a non-network provider, you must pay all of the charges and submit the bill to ValueOptions for those services that are covered and determined to be medically necessary.
Non-network Mental health is subject to a $1,000 annual deductible per enrollee, enrolled spouse/domestic partner and all dependent children combined, then reimbursed at 80% of reasonable and customary charges; once the combined family annual coinsurance maximum of $3,000 is met benefits are paid at 100% of reasonable and customary charges. The mental health deductible and out of pocket maximum is combined with the Empire Plan’s basic medical plan deductible and coinsurance maximums.
Non-network Substance Abuse benefits are reimbursed at 50% after deductible of the
ValueOptions network allowance. Outpatient services are reimbursed after the annual deductible per enrollee, enrolled spouse/domestic partner and all dependent children combined. Inpatient services are reimbursed after the annual deductible per enrollee, enrolled spouse/domestic partner and all dependent children combined (refer to the Basic Medical non-participating provider deductible and out-of-pocket maximum section)
To receive the maximum benefits, you must call ValueOptions before seeking care for mental health and substance abuse benefits (including alcoholism) and you must receive care from an ValueOptions participating provider. Failure to comply with these requirements will mean a reduced level of benefits.
ValueOptions does not replace HealthCall. ValueOptions only applies to mental health and substance abuse treatment. ValueOptions requirements affect all Empire enrollees and their covered dependents, even when Medicare or another plan is primary.
HOME CARE ADVOCACY PROGRAM (HCAP)
Call HCAP at 1-877-769-7447, option 1 and use an HCAP provider for medically necessary home care services, durable medical equipment (nebulizers, oxygen equipment, wheelchairs), skilled nursing services, enteral formulas prescribed by your doctor and you will receive paid-in-full benefits. Diabetic shoes have an annual maximum benefit of $500. HCAP requirements affect all Empire enrollees and their covered dependents, even when Medicare or another plan is primary. You will have no claim forms, and no out-of-pocket cost, no copayment, and no deductible by using the HCAP program.
If you do not use a participating HCAP provider, then you will be reimbursed up to a maximum of 50% of the network allowance after meeting the Basic Medical Program annual deductible. THE EMPIRE PLAN DIABETIC AND OSTOMY SUPPLIES PHARMACY (Liberty) Call Liberty at 1-888-306-7337, tell the network pharmacy that you are an Empire Plan enrollee and provide the prescribing doctor’s name and phone number. Liberty will confirm your need for the supply (glucometer, test strips, portable lancets, alcohol swabs and syringes) with your doctor. For insulin pumps and Medijectors, you must call HCAP for authorization at 1-877-769-7447, option 1 at the menu.
MANAGED PHYSICAL MEDICINE PROGRAM (MPN)
Call United Health Care at 1-877-769-7447, option 1 to make sure your physical therapist or chiropractor is participating in the program. All certified services are subject to just a $20 copayment. Non-network subject to a $250 deductible that is not included in the combined annual deductible and a 50% copayment.
BASIC MEDICAL PROVIDER DISCOUNT PROGRAM Deductible still applies
Based on negotiated rate, not R&C No balance billing over discounted rate
United HealthCare pays to the provider directly INFERTILITY TREATMENT BENEFIT
Paid in full benefits at a participating Center of Excellence ($50,000 lifetime allowance for qualified procedures) and no copayment for preauthorized Qualified Procedures. $20 copayment at other participating providers. At non-participating providers, Basic Medical deductible and coinsurance apply.
You must call United HealthCare at 1-877-769-7447, option 1 for authorization for the following Qualified Procedures: Artificial Insemination, Assisted Reproductive Technology (ART) procedures including in-vitro fertilization and embryo placement, Gamete Intra-Fallopian Transfer (GIFT), Zygote Intra-Fallopian Transfer (ZIFT), Intracytoplasmic Sperm Injection (ICSI) for the treatment of male infertility, assisted hatching and microsurgical sperm aspiration and extraction procedures; sperm, egg and/or inseminated egg procurement and processing and banking of sperm and inseminated eggs.
CANCER RESOURCE SERVICES
Centers of Excellence Program. Paid in full coverage for all services provided at a Cancer Resource Services network facility when the care is pre-certified. Call United HealthCare (1-877-769-7447, option 1) for further information.
GENERAL INFORMATION
Dual Annuitant Sick Leave Credit At retirement, enrollee elects either 100% credit for
life of enrollee OR 70% credit for life of enrollee and dependent survivors
Deferred Health Insurance Coverage Can choose to delay or defer health insurance
coverage in retirement
Domestic Partner Coverage Must provide proof of financial interdependence
for at least six months.
While every attempt has been made to ensure the accuracy of this summary, actual benefit payments are determined by the insurance companies.
